Educational Perspectives

Educational Strategies to Improve Outcomes from Neonatal

Resuscitation
Taylor Sawyer, DO, MEd*
*Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine and Seattle Children’s Hospital, Seattle,
WA

Education Gaps
1. Significant attention is paid to the science supporting neonatal
resuscitation guidelines, but little attention is paid to the science
supporting neonatal resuscitation education.
2. Failure to apply evidence-based educational strategies can have a
negative impact on the quality of neonatal resuscitation and decrease
survival after neonatal resuscitation.

AUTHOR DISCLOSURE Dr Sawyer has
disclosed no financial relationships relevant to
this article. This commentary does not contain
a discussion of an unapproved/investigative
use of a commercial product/device.
ABBREVIATIONS
AAP American Academy of Pediatrics
AHA American Heart Association
CMAT Cognitive aids in Medicine
Assessment Tool
DVD digital video disc
NRP Neonatal Resuscitation Program
PPV positive pressure ventilation
Abstract
Since 1987, the Neonatal Resuscitation Program (NRP) course has taught the
cognitive, technical, and behavioral skills required to effectively resuscitate
newborns. To remain relevant and effective, the NRP course needs to
continually evolve and embrace evidence-based educational strategies
proven to improve outcomes from resuscitation. In this Educational
Perspectives article, 6 educational strategies that can be applied to neonatal
resuscitation education are reviewed. These educational strategies include
mastery learning and deliberate practice, spaced practice, contextual learning,
feedback and debriefing, assessment, and innovative educational strategies.
Then knowledge translation and implementation of these educational
strategies through passive and active knowledge translation, change theory,
design thinking, performance measurement, deadoption strategies,
continuous quality improvement, incentive and penalties, and psychological
marketing are explored. Finally, ways to optimize faculty development of NRP
instructors, including both initial instructor training and ongoing instructor
development, are examined. The goal of this review is to help NRP program
developers and instructors use evidence-based educational strategies to
improve neonatal resuscitation outcomes.
Objectives After completing this article, readers should be able to:
1. Summarize the history of the Neonatal Resuscitation Program.

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 2. Describe the formula for survival in resuscitation.
3. Describe educational strategies that can improve outcomes from neonatal
resuscitation, if implemented optimally by trained faculty.
INTRODUCTION
Approximately 85% of all newborns start to breathe without
assistance within 15 seconds after birth. (1) Around 10% of
newborns require stimulation or suction to initiate sponta-
neous breathing. (2) Between 3% and 5% of newborns need
positive pressure ventilation (PPV) or intubation because of
a lack of spontaneous breathing after stimulation or suction-
ing. Less than 0.1% of newborns (1 in 1,000) require
cardiopulmonary resuscitation with chest compressions
and epinephrine. (3)(4) These statistics stress the impor-
tance of having a neonatal resuscitation team prepared to
provide lifesaving resuscitation at every delivery. (5) They
also highlight the critical importance of delivering effective
PPV during newborn resuscitation because the vast majority
of newborns who require resuscitation at birth will improve
with effective PPV. (6)
Since 1987, the Neonatal Resuscitation Program (NRP)
course has taught the cognitive, technical, and behavioral
skills required to effectively resuscitate newborns. (7) Today,
over 4 million health care professionals have been trained
or retrained in NRP, and about 200,000 learners complete
the NRP course each year. (8) More than 21,000 active NRP
instructors teach these courses. (8) The curriculum of the
NRP course has changed over time to keep pace with
advances in both medical science and adult learning theory.
(9) Since 2010 (6th edition), the NRP course has embraced
simulation as a critical educational strategy. (10) The current
(7th edition) NRP course format includes standardized
testing with an online multiple-choice examination, virtual
simulation with NRP eSIMTM, and an in-person course that
consists of 3 components: performance skills, integrated
skills, and simulation and debriefing. (10) To remain rele-
vant and effective, the NRP course needs to continually
evolve and embrace evidence-based educational strategies
shown to improve outcomes from resuscitation.
In 2018, the American Heart Association (AHA) pub-
lished a scientific statement titled “Educational Strategies
to Improve Outcomes from Cardiac Arrest.” (11) In that state-
ment, a modified formula for survival in resuscitation was
introduced. The statement identified 6 educational strate-
gies that could improve outcomes from cardiac arrest if
implemented optimally by trained faculty. In this educational
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perspective, I will review the AHA’s modified formula for
survival and examine how the 6 educational strategies could
be applied to neonatal resuscitation education. Then I will
explore knowledge translation and implementation of these
strategies through the NRP course. Finally, ways to optimize
faculty development of NRP instructors will be explored.
The goal of this review is to help NRP program developers
and instructors to use evidence-based educational strategies
to improve neonatal resuscitation outcomes.
THE MODIFIED FORMULA FOR SURVIVAL IN
RESUSCITATION
The Figure depicts a modified formula for survival in re-
suscitation from the AHA’s 2018 scientific statement, “Edu-
cational Strategies to Improve Outcomes from Cardiac
Arrest.” (11) The creation of the modified formula, and
the scientific statement that supports it, followed a multistep
process, including steering committee development, defin-
ing the scope of the statement, creating working groups,
performing a literature review, and performing a consensus-
building exercise at an AHA education summit. (11) The
new survival formula replaces the original AHA formula for
survival that was published in 2013. (12)
The modified formula for survival describes 3 interactive
factors that form a chain of survival after cardiac arrest. The
first factor is guideline quality, which is based on medical
science review by the International Liaison Committee on
Resuscitation and the development of consensus treatment
recommendations. (13) The second factor is the efficient
education of patient caregivers through resuscitation train-
ing courses such as the NRP. The third is the local imple-
mentation of the resuscitation guidelines and educational
activities, which involves health care professionals doing
what they learned in an NRP course as part of clinical
practice.
EDUCATIONAL STRATEGIES TO IMPROVE SURVIVAL
The modified formula specifies 6 educational strategies (eg,
instructional design features) associated with educational
efficiency. The 6 educational strategies include mastery
learning and deliberate practice, spaced learning, contextual
learning, feedback and debriefing, assessment, and innovative
educational strategies. Each of these strategies is reviewed in
the following subsections, and they are summarized in
Table 1. The content covered in this review does not include
an in-depth analysis of the evidence supporting the 6
educational strategies. What I provide here is a brief descrip-
tion of each strategy, including essential definitions, fol-
lowed by an example(s) of implementation of the strategy in
an NRP course. Readers interested in a comprehensive
summary of the evidence supporting each of the educational
strategies and an examination of implementation issues are
directed to the original publication. (11)
Mastery Learning and Deliberate Practice
Mastery learning and deliberate practice is an instructional
strategy used to ensure that students achieve a level of
mastery (eg, 90% on a skills test) during a training event
or educational course. As described by McGaghie, mastery
learning in health care education involves 7 essential ele-
ments. (14) The first 2 elements occur before the training
event. The first element is the development of a set of
learning objectives for the event or course. The second
element is the determination of a minimum passing stan-
dard (eg, mastery level) for each learning objective on an
assessment tool. (15)(16) During the training event, the
instruction starts with a diagnostic test for baseline skills.
After baseline skill has been measured, the students engage
in deliberate practice focused on reaching the learning
objectives and the preset mastery standard. To be deliberate,
the practice is paired with coaching, which is directed at the
diagnosis of errors in performance, informative feedback,
and remedial training to correct performance errors. (17)
During practice, formative testing is used to ensure that
each student’s performance has reached the preset mini-
mum passing standard for mastery. Continued deliberate
practice is used until each student reaches the mastery
standard. Only after the mastery standard has been reached
on the first learning objective can the student move to the
next learning objective. (14)
An example of the use of mastery learning and deliberate
practice in an NRP course is the implementation of a PPV
skills testing station in which all students are required to
demonstrate mastery to pass the NRP course. To implement
such a PPV skills testing station, there would need to be a
clear set of PPV learning objectives, and an assessment tool
would need to be developed to score PPV performance
accurately. A minimum passing standard (eg, mastery level)
on the checklist would also need to be determined. During
the training event, the course would start with a baseline
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diagnostic test of PPV skills. After baseline testing, each
student would engage in deliberate PPV practice focused on
reaching the preset mastery standard. The practice would be
paired with instructor coaching and feedback aimed at
correcting PPV performance errors. When ready, each
student would undergo formative testing to determine if
he/she reached the mastery standard. If not, continued
deliberate practice would be provided until each student
reached the mastery standard. A student who demonstrates
mastery on the baseline diagnostic test would not need
deliberate practice or formative testing.
Spaced Learning
Massed learning involves the acquisition of new knowledge
and skills during a single training event. Spaced learning
(also called spaced practice or distributed practice) involves the
acquisition of new knowledge and skills during several
discrete sessions that are separated in time. (11) The number
of sessions and the intervals between sessions can vary, but
the sessions are typically minutes to hours in length and
typically separated by days to weeks.
The educational benefits of spaced learning stem from a
psychological phenomenon called the spacing effect, which is
based on cognitive load theory. (18) Cognitive load theory
posits that human memory is made up of 2 types: long-term
memory and working memory. (19) The capacity of long-
term memory is limitless. The capacity of working memory
is limited to 7–2 units at a time. Learning new knowledge
and skills requires cognitive work (eg, cognitive load) as
working memory organizes and stores new information in
long-term memory where it can be retrieved later. When the
capacity of a learner’s working memory to store new infor-
mation in long-term memory is exceeded, the learner is
overloaded (eg, cognitive overload) and is unable to process
new information effectively. By breaking up learning into
small portions over a dispersed period, the cognitive load to
the learner is decreased or is less likely to occur. (20)
The differentiation between initial training to gain new
knowledge and skills and follow-up training to retain knowl-
edge and skills that have already been learned is essential.
Initial training is aimed at novice learners to achieve a
baseline level of competency. Once competency is achieved,
follow-up training is needed to retain knowledge and pre-
vent skill decay. Sullivan et al recently described 3 types of
follow-up training. (21) In that report, the authors define
maintenance training as low-dose high-frequency training
aimed at preventing skill decay in a competent provider.
Booster training is provided less frequently but with higher
intensity and is intended to overcome some level of skill
decay that has occurred. Refresher training is aimed at
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 TABLE 1. Overview of Educational Strategies to Improve Neonatal
Resuscitation Outcomes and Examples of Use in an NRP Course
EDUCATIONAL STRATEGIES DEFINITION EXAMPLE OF USE IN AN NRP COURSE

Mastery learning and deliberate
practice
Spaced practice
Contextual learning
Feedback and debriefing
Assessment
Innovative educational strategies
An instructional strategy that uses repeated practice Requirement to score ‡90% on a PPV skill
and coaching to ensure that each student assessment to pass the NRP course
achieves a level of mastery during a training event Students continue to practice until they reach the
90% score
An instructional strategy in which new knowledge Designing an NPR course that uses several spaced
and skills are learned over several sessions practice sessions distributed over days to weeks
separated in time, rather than during a single At each NRP session a new knowledge chunk or skill
session is introduced
Providing educational content that applies to the A basic NRP course for low-risk birth attendants with
learner’s real-world scope of practice and the a focus on the basic airway skills of PPV and
practice environment laryngeal mask placement, and the behavioral
skills of knowing the environment, anticipating
and planning, and calling for help
An advanced NRP course for high-risk birth
attendants that includes all the procedural skills
needed for a full restitution including intubation,
chest compressions, and medication
administration, and the behavioral skills of team
leadership, communication, and delegation of
work
Feedback is the provision of information about the Feedback: NRP instructor coaching a student on
performance compared with a standard PPV performance during an NRP course, or a
student receiving automatically generated
feedback from a neonatal simulator that
measures the quality of PPV
Debriefing is a reflective conversation about Debriefing: A reflective discussion led by the NRP
performance instructor after a neonatal resuscitation
simulation. The discussion should address task
work, teamwork, and any performance gaps. The
overall focus of the conversation is performance
improvement
A method of obtaining information from tests and Assessment of cognitive skill using an online
other sources, and using that information to draw multiple-choice examination that is completed
inferences about the competency of an NRP before the classroom portion of the NRP course
course participant’s cognitive, technical, and
behavioral skills
The assessment must involve a method that has A technical and behavioral skills assessment during
evidence of validity to ensure that it accurately the classroom portion of the NRP course by a
measures what it is intended to measure well-trained NRP instructor using an instrument
with strong evidence of validity
Innovative educational strategies that can be used to Gamified learning: Using NRP eSim as part of
supplement existing resuscitation education and neonatal resuscitation training and/or skill
aid in the dissemination of resuscitation-related retention
information
Examples include gamified learning, social media, Social media, blogs and podcasts: Using Facebook,
blogs and podcasts, and crowdsourcing Twitter, YouTube, blogs, and podcasts to
disseminate information about a recently
published change to the neonatal resuscitation
guideline
Crowdsourcing: Using the power of the crowd to
determine the format and visual layout of the
neonatal resuscitation algorithm

Adapted from Cheng et al. (11) NRP¼Neonatal Resuscitation Program; PPV¼positive pressure ventilation.

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reestablishing skills after competency has been lost. Re-
fresher training is of higher intensity than booster training
and is more akin to initial training (eg, retraining). Each of
these follow-up training types are distributed in time (eg,
spaced), but the learning strategy technically should not be
called “spaced learning” because the focus is on knowledge
and skill retention, rather than initial acquisition.
An example of the use of spaced training in an NRP
course would be to change the format of the course from
massed learning sessions (a course completed in 3–4 hours)
to several spaced learning sessions distributed over days to
weeks. At each NRP session, a new knowledge chunk or skill
could be introduced. For example, during session 1, the
initial steps of neonatal resuscitation could be reviewed. A
few days later, during session 2, PPV could be taught. A few
days after that session, the students could learn chest
compressions. Thus, the training that was encapsulated
in a single 3- to 4-hour session would instead be spaced
over several sessions for a total of 3 to 4 hours. Hence, the
total dose of education is the same, but the administration of
the educational dose differs.
Contextual Learning
Contextual learning is an educational theory that suggests
that learning occurs best when information is presented in
such a way that students can construct meaning based on
their own experiences. Critical factors for contextualization
resuscitation training include providing educational content
that applies to the learner’s real-world scope of practice and
conducting the training in an environment that mimics the
learner’s real-world practice environment. (11) Failure to
optimize the context of training can negatively affect learn-
ing outcomes. (11)
An example of the use of contextual learning in an NRP
course is the development of different types of NRP courses
for specific learner groups. For each NRP course, the context
of the course would be aligned with the student’s real-world
scope of practice and the practice environment. For exam-
ple, one could imagine a basic NRP course that is contex-
tually aligned with the real-world scope of individuals who
attend low-risk births and those who have additional help
immediately available, such as midwives and labor and
delivery nurses in a hospital with a NICU. In such a course,
the educational content would only include the procedural
skills those individuals are licensed to perform, such as
initial steps, PPV, and laryngeal mask placement. Similarly,
one could imagine an advanced NRP course that is contex-
tually aligned with the real-world scope of individuals who
attend high-risk births, and those who do not have addi-
tional help immediately available, such as neonatologists,
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neonatal nurse practitioners, and paramedics. In such a
course, the educational content would include all the pro-
cedural skills needed for a full resuscitation, including
intubation, chest compressions, and medication adminis-
tration. In addition to differences between the basic and
advanced courses in procedural skills, behavioral skills
would also differ. Behavioral skills learning objectives in
the basic NRP course would focus on knowing the envi-
ronment, anticipating and planning, and calling for help.
Behavioral skills learning objectives in the advanced NRP
course would focus on team leadership, communication,
and delegation of work.
Feedback and Debriefing
Both feedback and debriefing deal with giving information
about performance to a student or group of students.
Performance information can include both taskwork (eg,
what was done) and teamwork (eg, how team members
performed together). (22) Feedback is the provision of
information about performance in comparison to a stan-
dard. (23) Debriefing is a reflective conversation about
performance. (24)(25)(26) During the debriefing conver-
sation, however, some feedback may be provided. Both
feedback and debriefing are fundamental elements of
resuscitation education. A better understanding of how
to structure feedback and debriefing during resuscitation
education may enhance the effectiveness of training. (11)
Participants and instructors of NRP courses should be
familiar with feedback and debriefing. An example of feed-
back in an NRP course is coaching provided by an NRP
instructor to a student at a PPV performance skills station.
(27) Another example would be the automatically generated
data from a simulator designed to measure the quality of
PPV. Such a simulator could provide students with infor-
mation on tidal volume delivered, respiratory rate, and mask
leak, which they could see in real-time and use to improve
performance. An example of debriefing in an NRP course is
the reflective discussion that takes place after neonatal
resuscitation simulations that take place during the simu-
lation and debriefing portion of the course. As part of that
debriefing conversation, the team reviews its performance
on both taskwork and teamwork, and the NRP instructor can
provide feedback as needed to correct performance gaps.
Assessment
Assessment is a method of obtaining information from tests
and other sources and using that information to draw
inferences about the characteristics of people, objects, or
programs. (28) In resuscitation education courses, the
characteristics being assessed typically include competency
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 in cognitive, technical, or behavioral skills of the resuscita-
tion. Assessment can have high stakes (eg, a test used to
determine passing or failing the course) or low stakes (eg, an
assessment made by an instructor to provide specific feed-
back) Assessment of competence is a critical component of
high-quality resuscitation education. Therefore, the assess-
ment strategy should be a key consideration in resuscitation
education course design. Students’ cognitive, technical, or
behavioral skills are complicated, however, and not always
directly observable. Therefore, assessment of students’ abil-
ities in these areas relies on inferences made from the
available assessment evidence. Hence, drawing accurate
inferences requires accurate assessment methods.
Validity is the most crucial characteristic of any assess-
ment method. (11) Validity is the extent that an assessment
accurately measures what it is intended to measure. (29)
Contemporary frameworks of validity present validity as an
argument or a testable hypothesis. As such, validity cannot
be proven or disproven, but can only be supported or re-
futed by available evidence. (29) Therefore, an assessment
method cannot be described as valid or invalid, but rather,
defined according to the level of evidence that supports or
refutes the interpretations being made with it. In the past,
validity evidence was commonly divided into multiple types.
These included content validity, criterion validity, construct
validity, and others. Contemporary frameworks of validity
consider validity to be a unitary concept, wherein construct
validity represents the whole of validity. (30)
Based on this contemporary interpretation, it is crucial to
be clear about what characteristic an assessment method
is measuring (eg, cognitive, technical, or behavioral skills)
when constructing a validity argument. Two threats to the
validity of assessment data are construct underrepresenta-
tion and construct-irrelevant variance. (31) Construct under-
representation refers to the inadequate sampling or biased
sampling of the characteristic being assessed. Construct-
irrelevant variance indicates a systematic error (eg, not
random error) in the assessment data by variables unrelated
to the characteristic being assessed. Both types of threat
decrease the strength of the validity argument by reducing
the ability to make reasonable inferences from the assess-
ment data obtained.
The current 7th edition of the NRP course includes 2
formal assessment methods. The first is the multiple-choice
examination that is completed online before the classroom-
based portion of the course. The multiple-choice examina-
tion is intended to assess a student’s cognitive skill. All
students are required to pass the test before attending the
classroom portion of the course. A psychometric analysis of
the NRP online examination is performed regularly to
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evaluate its level of validity. The questions on the test are
amended as needed by the NRP steering committee to
ensure a high level of construct validity. The second assess-
ment method is the integrated skills station. This method
assesses a student’s technical and behavioral skills. This
assessment takes place during the classroom portion of the
NRP course and is performed by the NRP instructor. All
students are required to pass the integrated skills station to
receive NRP provider status (eg, an NRP card). The con-
struct validity argument for this assessment is much lower
than that of the online examination. Threats to the validity of
the performance assessment done during the integrated
skills station include both construct underrepresentation
and construct-irrelevant variance. (31) Specific threats to
include are the availability of too few cases for generaliz-
ability, use of an indefensible passing score method, rater
bias, and poorly trained rater. The assessment of technical
and behavioral skills during the NRP course could be
improved by using assessment instruments with docu-
mented evidence of validity. (32)(33)(34)(35) Training NRP
instructors on how to use assessment instruments is an
important consideration and is discussed later in the section
on faculty development.
Innovative Educational Strategies
The AHA’s scientific statement entitled “Educational Strat-
egies to Improve Outcomes from Cardiac Arrest” identified
4 innovative educational strategies that can be used to
supplement existing resuscitation education. The 4 strate-
gies include gamified learning, social media, blogs and pod-
casts, and crowdsourcing. (11) Gamified learning (also known
as gamification or serious games) is an educational strategy
designed to increase the enjoyment and engagement of
students by using video game design principles and game
elements in learning environments. Resuscitation educa-
tion games are typically computer-based, and a student
initiates actions using a mouse or keyboard. Virtual reality
games—in which a student’s hand movements are tracked
—are also possible. These self-directed screen-based games
typically focus on cognitive skills and decision-making
involved in resuscitation. (11) The benefits of using serious
games include the consistent delivery of educational con-
tent, the ability to learn without an instructor, flexibility in
the timing of content delivery, and lower cost. (36)
Social media is user-generated content that enables dis-
semination, collaboration, and interaction on various online
platforms, such as Facebook, Twitter, and YouTube. (37)
When best practices for accuracy and timeliness are fol-
lowed, social media can increase engagement and support
knowledge exchange within communities of resuscitation
providers and instructors. (11)
Blogs are self-published written content, which can
include embedded links, graphics, and interactive discus-
sion forums. Podcasts are recorded audio content accessible
online or through smartphone applications. Like social
media, both blogs and podcasts are powerful tools for
information dissemination. Several studies have confirmed
the capacity of blogs and podcasts to act as supplementary
learning tools to improve the dissemination of research. (11)
Crowdsourcing is using groups of individuals to perform
a task that is usually performed by individuals or organiza-
tions. (38) Potential applications of crowdsourcing in resus-
citation education include using crowdsourcing to develop,
vet, and vote on resuscitation educational materials, and
using crowdsourcing to evaluate resuscitation performance.
However, data on such innovative educational strategies are
limited, and issues of quality control and conflicts of interest
need to be explored before crowdsourcing is widely used.
(11)
An example of gamification in the NRP course is NRP
eSim (AHA/American Academy of Pediatrics [AAP]), an
online computer-based simulation exercise that allows
learners to practice the steps of neonatal resuscitation in
a virtual environment. NRP eSim was introduced with the
7th edition of the NRP curriculum and is enjoyed by many
NRP students. (10) Research is ongoing to examine the
educational benefits of NRP eSim. (39) Multiple other
examples of serious neonatal resuscitation games exist,
including the Neonatal Resuscitation Game (National
Health Service, Education for Scotland, Edinburgh, UK),
the Singaporean Neonatal Resuscitation Game (Singapore
General Hospital, Singapore), e-Baby (University of São
Paulo, São Paulo, Brazil), the Compromised Neonate Pro-
gram (University of Newcastle, Callaghan, Australia), and
Electronic Helping Babies Breathe (University of Washing-
ton, Seattle, WA, and Oxford University, Oxford, UK). (36)
An example of using social media, blogs, and podcasts to
supplement existing resuscitation education is by using
these outlets to disseminate findings from newly published
AHA focused update on neonatal resuscitation or updates to
the AHA neonatal resuscitation guidelines. (40) The NRP
maintains a Facebook page that has been used for this
purpose. (41) One potential use of crowdsourcing in neo-
natal resuscitation education is to use the power of the
crowd to determine the design properties (eg, format and
visual layout) of the neonatal resuscitation algorithm. In
such an exercise, the crowd could use the Cognitive aids in
Medicine Assessment Tool (CMAT) to score different ver-
sions of the algorithm. (42) The CMAT does not evaluate the
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appropriateness of the content, but only scores the visual
presentation of information, such as clearly linking explan-
atory notes to the corresponding action item. Such an
exercise could be used better to configure the neonatal
resuscitation algorithm as a cognitive aid to ensure that
the information is accessible in an emergency. (43)
KNOWLEDGE TRANSLATION AND IMPLEMENTATION
The formula for survival depicted in the Figure describes the
3 interactive factors of the resuscitation guidelines: quality
(medical science), efficient education of health care providers
(education efficiency), and a functional chain of survival at the
local level (local implementation). A key to achieving both
education efficiency and local implementation is to optimize
knowledge translation and implementation of the resusci-
tation guidelines. Knowledge translation and implementa-
tion of guidelines are critical because, without them, even
the best, most evidence-based, neonatal resuscitation guide-
lines will have no clinical impact because no one will know
about them and no one will implement them. Therefore,
examining ways to optimize knowledge translation and
implementation of neonatal resuscitation guidelines is
essential.
Current methods for translating knowledge from new
resuscitation guidelines and implementing them into clin-
ical care result in significant delays in implementing new
science. Prior studies through the Resuscitation Outcomes
Consortium showed that the time from publication of the
2005 basic and advanced life support resuscitation guide-
lines to implementation in emergency medical services
agencies ranged from 49 to 750 days. (44) Barriers to
implementation of new guidelines included resistance to
change, delays in the training material supply chain, finan-
cial costs of training, the need to replace outdated technol-
ogy, regulatory hurdles, and isolation between guideline
writers and the providers who were responsible for local
implementation. (45) Studies of barriers to the implemen-
tation of neonatal resuscitation guidelines have identified
disruption of existing workflow, staff attitudes about incor-
porating additional tasks and responsibilities into their
ongoing work, and variation in resources as key thematic
barriers. (46)
Finding ways to speed the adoption of new scientific
guidelines and overcome barriers to implementation is an
active area of investigation. Table 2 provides an overview of
the knowledge translation and implementation strategies
identified in the AHA’s scientific statement on resuscitation
education science. (11)(47)(48) In addition to the specific
methods and their definition, the table includes some
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 Figure. The modified formula for survival in resuscitation from the American Heart Association’s 2018 scientific statement by Cheng et al. (11) Used
with permission.
specific suggestions for how each method could be applied
to the NRP.
FACULTY DEVELOPMENT
The AHA’s modified formula for survival highlights the
critical importance of faculty development for both educa-
tional efficiency and local implementation (Figure).
Faculty development includes a set of strategies to improve
the knowledge, skills, and attitudes of resuscitation course
instructors so they can initially acquire and then subsequently
maintain the skills necessary to teach resuscitation courses
effectively. (11) Like the content of the courses they teach, the
design of faculty development efforts should be informed by
science and rely on evidence-based education strategies. The
AHA’s scientific statement on resuscitation education sci-
ence summarizes the literature on resuscitation course fac-
ulty development strategies and provides recommendations
for improvements in faculty development based on education
science. (11) The statement divides faculty development
efforts into 2 phases: initial instructor training and ongoing
instructor development. (49)
Initial instructor training is the preparation of an indi-
vidual(s) to teach a resuscitation course. This preparation is
typically accomplished through instructor training pro-
grams, workshops, seminars, and the giving and receiving
of feedback (eg, coaching). Initial instructor training pro-
grams provide instructors with a solid foundation in the
scientific evidence behind the resuscitation guidelines taught
in the course. They also provide instructors with the skills
needed to teach the course effectively. This includes ap-
proaches to dealing with common challenges, coaching, the
ability to effectively debrief others, contextualizing course
content to various audiences, and facilitating the develop-
ment of teamwork training. (11)
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The NRP has used various methods for initial instructor
training. With the 6th edition, released in 2011, the NRP
changed its education methodology, shifting from the NRP
instructor as a “teacher” to a “learning facilitator.” This
included a change from a lecture format course design to
simulation-based learning design. To help NRP instructors
learn these new skills and meet the new requirements, the
NRP created and launched the NRP instructor digital video
disc (DVD) “An Interactive Tool for Facilitation of Simulation-
based Learning.” The interactive DVD familiarized instruc-
tors with simulation and guided them on ways to incorporate
simulation into NRP courses. With the 7th edition, released
in 2016, the NRP retired the instructor DVD and launched
an online NRP instructor candidate bundle. The bundle is
accessible via the NRP learning management system, and
includes 2 parts: part 1—completing the NRP instructor
course learning activity, passing the instructor examination,
and accessing the NRP eSim cases; and part 2—coteaching 2
instructor-led events under the guidance of an instructor
mentor, and completing the “debrief the debriefer” checklist.
Ongoing instructor development is the ongoing improve-
ment of instructors’ skills as they teach a resuscitation course
over time. Some strategies for ongoing instructor development
include creating systems to support instructors to be self-
directed, lifelong learners, with mechanisms that enhance
reflective practice and peer coaching. Helping instructors to
become change agents, not just teachers, is essential and
requires instructors to look beyond the classroom and imple-
ment strategies to ensure that students perform optimally in
the clinical environment. Developing a community of practice
for resuscitation course instructors is also vital. (11)
The NRP has been devoted to ongoing instructor devel-
opment since the inception of the course. Today, the ongo-
ing development of NRP instructors is accomplished
through several methods. The primary method is the online
TABLE 2. Methods for Knowledge Translation and Implementation of NRP
Guidelines
METHOD
Passive and active knowledge
translation
Change theory
Design thinking
Performance measurement
Deadoption strategies
Continuous quality improvement
Incentive and penalties
Psychological marketing
Adapted from Cheng et al. (11) AHA¼American Hospital Association; NRP¼Neonatal Resuscitation Program.
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DEFINITION SUGGESTIONS
Passive knowledge translation means that potential NRP should use both passive and active knowledge
knowledge users must seek out the information translation techniques to improve awareness,
themselves. Examples include searching for adoption, and adherence to NRP guidelines. This
academic publications and accessing the includes publishing the guidelines in medical
information contained in an online instructor journals and also pushing those publications to
toolkit health care personnel and NRP instructors to
Active knowledge translation includes actions that ensure that changes are recognized and
target and push information to potential implemented
knowledge users directly without the recipient
needing to seek the information. Examples
include email blasts and social media strategies
Change theory examines how to best communicate NRP should consider change theory to address
and facilitate change in the human context, taking barriers to change when introducing new
into consideration human biases and behavioral scientific guidelines
responses to change
Design thinking involves the planning of the physical NRP should consider the physical space(s) in which
environment and takes into account human neonatal resuscitation occurs and consider
factors and ergonomics human factors and ergonomics into its
resuscitation guidelines to support people by
making it easy to do the right thing within the
neonatal resuscitation environment
Performance measurement is the collection of data NRP should collaborate with performance
on measurable events such as time to start measurement programs that include
positive pressure ventilation, use of pulse benchmarks, feedback, and public reporting on
oximetry, and placement of an advanced airway neonatal resuscitation quality metrics such as the
before the start of chest compressions AHA Get with The Guidelines-Resuscitation
(GWTG-R) to allow health systems to measure
and improve neonatal resuscitation performance
(47)
Deadoption, or unlearning, is the systematic NRP should develop strategies to help NRP
deimplementation of an entrenched practice. An providers rapidly deadopt practices that are
example is the discontinuation of suctioning affected by new resuscitation guidelines (48)
nonvigorous newborns with meconium-stained
fluids
Continuous quality improvement is a structured NRP should help providers and hospitals adopt
organizational method to improve the processes formal continuous quality improvement
of care with a goal to provide improved health programs for neonatal resuscitation. This effort
care outcomes could include defining and publishing
resuscitation quality metrics for the newly born
(47)
Performance modification through the use of NRP should incentivize organizations to achieve
positive rewards (incentives) or negative high compliance with newly born resuscitation
consequences (penalties) quality metrics by giving NRP resuscitation
awards to health systems that achieve high
compliance with neonatal resuscitation quality
metrics
Psychological marketing identifies methods to NRP should use psychological marketing
communicate messages in a way that resonates techniques to craft messages and informational
with the target audience campaigns that appeal directly to the beliefs and
emotions of health care providers, regulatory
agencies, and funders
Vol. 21 No. 7 JULY 2020 e439
 NRP instructor toolkit, which is an online repository of NRP
instructor resources within the NRP learning management
system, including tools, tips, checklists, forms, video clips,
blogs, webinars, podcasts, etc. In addition to the toolkit,
NRP also publishes a biannual NRP instructor update
newsletter. The newsletter is written by members of the
NRP steering committee and invited authors. (50) In addi-
tion to the instructor toolkit and newsletter, NRP holds
many in-person education sessions for instructors. These
include the yearly NRP current issues seminar held in
conjunction with the AAP national conference and exhibi-
tion and series of NRP “road shows” that were held across
the United States in 2019 and 2020. With the 8th edition of
the NRP course curriculum, to be released in 2021, the
methods used for initial instructor training and ongoing
instructor development will continue to evolve and improve.
CONCLUSION
In this educational perspectives article, I examined the
AHA’s modified formula for survival in resuscitation and
reviewed 6 educational strategies to improve survival in
neonatal resuscitation, including mastery learning and
deliberate practice; spaced practice; contextual learning;
feedback and debriefing; assessment; and innovative edu-
cational strategies. I then explored knowledge translation
and implementation of these strategies through the NRP
course. Finally, I reviewed the faculty development require-
ments for NRP instructors to implement these educational
strategies into an NRP course effectively. The goal of this
review is to help NRP program developers and NRP in-
structors effectively use educational strategies to improve
neonatal resuscitation outcomes. Application of these
evidence-based resuscitation education strategies may in-
crease neonatal resuscitation quality and subsequently im-
prove survival after neonatal resuscitation.
American Board of Pediatrics
Neonatal-Perinatal Content
Specifications
• Know the proper approach to airway management in the delivery
room.
• Know the incidence, causes and pathophysiology, including
cellular abnormalities, of acute perinatal asphyxia.
• Know the causes and pathophysiology, including cellular
abnormalities, of chronic asphyxia syndromes (eg, chronic fetal
hypoxia and placental insufficiency).
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Vol. 21 No. 7 JULY 2020 e441
 Educational Perspectives: Educational Strategies to Improve Outcomes from
Neonatal Resuscitation
Taylor Sawyer
NeoReviews 2020;21;e431
DOI: 10.1542/neo.21-7-e431

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Educational Perspectives: Educational Strategies to Improve Outcomes from
Neonatal Resuscitation
Taylor Sawyer
NeoReviews 2020;21;e431
DOI: 10.1542/neo.21-7-e431

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
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